Healthcare Provider Details

I. General information

NPI: 1760463640
Provider Name (Legal Business Name): HEIDE KATHLEEN CRANDALL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 MARTIN STREET
WELLSVILLE NY
14895
US

IV. Provider business mailing address

46 MARTIN STREET
WELLSVILLE NY
14895
US

V. Phone/Fax

Practice location:
  • Phone: 585-593-9497
  • Fax: 585-596-4048
Mailing address:
  • Phone: 585-593-9497
  • Fax: 585-596-4048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number210775
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: